Confidentiality agreement (third parties)

I, the undersigned (surname, first name, date and place of birth):


(Tel + optional GSM):

having participated as a trainee, in the specific capacity of an observer, under the supervision of José Rafael Mata Dona, in the mediation process between A and B, shall be bound by professional secret and the duty of discretion.

I undertake to comply with the requirements of article 458 of the Penal Code, namely:

Physicians, surgeons, health officers, pharmacists, midwives and other persons who, by state or profession, are entrusted with the secrets entrusted to them, unless they are called upon to give evidence in court (or before a parliamentary commission of inquiry) or the law obliges them to disclose such secrets, if they reveal the entrusted secrets, they shall be punished by imprisonment of eight to six months and a fine of one hundred euros to five hundred euros. 

I therefore undertake to assume the utmost discretion in all matters relating to the facts and information of which I am aware in the performance of my duty as an observer and to communicate in any form whatsoever no information or information which would not have been made public.

These obligations remain after completion of the training.

Done in …………………………….(place), on …………………………(date) in……(number) original copies, one for each party and their eventual counsel and one for the mediator, each of them acknowledging receipt of one.

Le superviseur, médiateur agrée auprès
de la Commission fédéral Belge de Médiation

José Rafael Mata Dona